Proposal Part One.
The Assessment and Management of Suicide Risk: State of Workshop Education
ANTHONY R. PISANI, PHD, WENDI F. CROSS, PHD, AND MADELYN S. GOULD, PHD, MPH
A systematic search of popular and scholarly databases identified workshops that addressed general clinical competence in the assessment or management of suicide risk, targeted mental health professionals, and had at least one peer- reviewed publication. We surveyed workshop developers and examined empirical articles associated with each workshop. The state of workshop education is char- acterized by presenting the learning objectives, educational formats, instructor factors, and evaluation studies. Workshops are efficacious for transferring knowl- edge and shifting attitudes; however, their role in improving clinical care and outcomes of suicidal patients has yet to be determined.
Mental health professionals have a valuable role to play in preventing suicide. Suicidal symptoms, risk, and behavior are common among patients in mental health settings due to the prevalence of mental disorders and other risk factors (Brown, Beck, Steer, & Grisham, 2000; Harris & Barraclough, 1997; Palmer, Pankratz, & Bostwick, 2005). In recognition of the role clinicians play in pre- venting suicide, the 1999 Surgeon General’s Call to Action (U.S. Public Health Service, 1999) and the 2001 National Strategy for Suicide Prevention (NSSP; U.S. Dept. of Health and Human Services, 2001) included objectives for enhancing the pool of mental health professionals competent in the assess- ment and management of suicide risk by improving training at the graduate level (NSSP Objective 6.3) and assuring contin-
uing clinical competence of practicing pro- fessionals (NSSP Objective 6.9). Competent recognition, screening, and care of individu- als at risk for suicide have also been a focus of accreditation and regulatory bodies (e.g., The Joint Commission) and state offices of mental health. The demand for competence in this area of practice is also increasing in research settings. Investigators interested in studying effectiveness in naturalistic settings increasingly recruit individuals with suicidal ideation and history of suicide attempts for studies. The inclusion of these individuals in research studies necessitates suicide risk management protocols and consultation from suicide risk assessment experts (Oquendo, Stanley, Ellis, & Mann, 2004; Pearson, Stanley, King, & Fisher, 2001).
Clinical work with individuals at risk for suicide is anxiety provoking and increas- ingly complicated (Jobes, Rudd, Overholser, & Joiner, 2008). Clinicians have a practical and ethical responsibility to develop and maintain clinical competence in this area of practice. Epstein and Hundert (2002) defined competence in medicine as ‘‘the habitual and judicious use of communica- tion, knowledge, technical skills, clinical rea- soning, emotions, values, and reflection in
ANTHONY R. PISANI, Psychiatry and Pediat- rics, University of Rochester; WENDI F. CROSS, Psychiatry (Psychology) and Pediatrics, University of Rochester; MADELYN S. GOULD, Psychiatry and Epidemiology, Columbia University/New York State Psychiatric Institute.
Address correspondence to Anthony R. Pisani, Psychiatry and Pediatrics, University of Rochester, Rochester, NY, USA; E-mail: anthony_pisani@urmc.rochester.edu
Suicide and Life-Threatening Behavior 41(3) June 2011 255 � 2011 The American Association of Suicidology
daily practice for the benefit of the individu- als and communities being served.’’ This definition is apt for the study of suicide- specific competence because it captures the range of personal, professional, intellectual, and technical capacities required to work effectively with individuals at risk. Experts in clinical suicidology have developed prac- tice guidelines (Jacobs & Brewer, 2004) and core competencies (Suicide Prevention Resource Center, 2006) specific to the assess- ment and management of suicidal risk and behavior. Consistent with Hundert and Epstein’s broad understanding of compe- tence, these guidelines and competencies address multiple domains of practice. For example, the task force convened by the American Association of Suicidology (AAS) and the Suicide Prevention Resource Center (SPRC) identified 24 competencies in 7 domains of practice (attitudes and approach, understanding suicide, collecting accurate assessment information, formulation of risk, treatment and services planning, manage- ment of care, and legal–regulatory issues; Suicide Prevention Resource Center, 2006).
Clinicians develop competence in working with individuals at risk for suicide through formal and informal educational venues. These venues vary on investment required, proximity to practice, and assur- ance of quality and expertise. This article focuses on in-person, expert-led, suicide- specific workshops designed for mental health professionals. For the purposes of this study, a workshop is a brief intensive educa- tional program that focuses on techniques and skills in assessing and managing suicide risk. This study is the first to systemati- cally gather, organize, and critique informa- tion about these workshops, so clinicians, researchers, and administrators can evaluate available education options and the evi- dence base for approaches to building com- petence in the mental health workforce. Our aims are to (1) describe the educational objectives and methods of the workshops; (2) characterize the training and qualifications of the trainers who deliver the workshops; and
(3) review published studies about the train- ing programs’ outcomes.
METHOD
Program Identification
We searched popular and scholarly databases and queried a suicidology listserv to identify all possible English-language edu- cational offerings that met the following criteria:
Criterion 1: The target audience is primarily mental health professionals. We defined mental health professional as a person who offers services for the purpose of improv- ing an individual’s mental health or to treat mental illness. This broad category includes psychiatrists, clinical psychologists, clinical social workers, psychiatric nurses, mental health counselors, and other professionals.
Criterion 2: The program’s educa- tional objectives target general clinical com- petence in assessment and management of risk for suicide. We defined general clinical competence as the collection of knowledge, attitudes, and skills that any mental health professional should possess when working with individuals at risk for suicide, regardless of the treatment paradigm, protocol, or tech- nique the professional chooses to apply. Workshops that aim to train mental health professionals in the use of a particular treat- ment manual or protocol, such as dialectical behavioral therapy (DBT; Linehan, 1993) or cognitive-behavioral therapy for suicide pre- vention (CBT-SP; Stanley et al., 2009), are not considered programs that target general clinical competence in the assessment and management of suicide risk.
Criterion 3: At least one peer-reviewed article describes or evaluates the training or explicates the clinical model upon which the training is based. A workshop for mental health professionals that grew out of a com- munity gatekeeper training that had been the subject of a peer-reviewed article would meet this criterion, even if no peer-reviewed article
256 STATE OF WORKSHOP EDUCATION
had been published specifically about the workshop for mental health professionals.
Popular Database Search Procedure. We used the Google and Yahoo search engines to identify workshops advertised for mental health professionals. During the first round of searches we reviewed the first 100 results of a two-term Boolean search: ‘‘suicide’’ AND (‘‘training’’ OR ‘‘education’’ OR ‘‘continuing education’’ OR ‘‘workshop’’). During the sec- ond round of searches we reviewed the first 100 results of a three-term Boolean search that fur- ther specified the results: ‘‘suicide’’ AND (‘‘training’’ OR ‘‘education’’ OR ‘‘continuing education’’ OR ‘‘workshop’’) AND (‘‘clini- cian’’ OR ‘‘mental health professional’’ OR ‘‘counselor’’ OR ‘‘therapist’’ OR ‘‘psychia- trist’’). We reviewed all webpage titles for the first 100 results from each search and reviewed linked pages whenever necessary. The review of popular database results yielded 19 work- shops that met Criterion 1 and 2.
Scholarly Database Search Procedure. We searched PsychInfo and Medline for each of the 19 workshops identified via the popular database search to identify peer- reviewed articles (Criterion 3) that described or evaluated any aspect of the training offered to mental health professionals or the model upon which the training was based. To identify articles we conducted keyword searches using variations of the workshop titles and the names of the workshop devel- opers. Six of the 19 programs identified by the popular database search met this publica- tion criterion for inclusion in the study.
We conducted a second series of PsychInfo and Medline searches to identify any educational offerings that the popular searches had not uncovered. We reviewed the results of the following two-term Boolean searches in PsychInfo: ‘‘suicide’’ AND (‘‘education’’ OR ‘‘continuing education,’’ OR ‘‘clinical methods training’’) and ‘‘sui- cide’’ AND (‘‘competence’’ OR ‘‘professional competence’’). The keyword thesauruses of PsychInfo and Medline databases differ slightly (Tuleya, 2007; U.S. National Library of Medicine, 2008), so the term suicide was combined with a slightly different set of terms
in the Medline database: ‘‘suicide’’ AND (‘‘education’’ OR ‘‘continuing education’’) and ‘‘suicide’’ AND ‘‘professional compe- tence.’’ We excluded articles about ‘‘assisted suicide’’ and articles published before 1980. This set of searches yielded four additional workshops that met Criteria 1, 2, and 3.
Suicidology Listserv Query. We queried members of the American Psychological Association ‘‘Suicidology’’ listserv (American Psychological Association, 2007) with our list of identified workshops and requested infor- mation on any additional educational offer- ings. The message was distributed on March 17, 2009, to 442 listserv recipients. The query yielded responses from three program repre- sentatives. One of these additional workshops met inclusion criteria. The other two pro- grams targeted community gatekeepers.
Program Developer Survey
Respondents. We e-mailed the devel- opers of the 11 workshops that met the inclu- sion criteria with a request and hyperlink to participate in a brief online survey about their programs. We described the inclusion criteria that yielded the invitation to partici- pate and asked the developers to complete the survey or designate another knowledge- able person to do so. One of the developers (Shea) alerted us to a second workshop offered by his institute. We confirmed that this workshop met inclusion Criteria 1, 2, and 3 via a Medline literature search and arti- cles submitted by the developer. We asked the developer to complete a survey about this program. Thus, a total of 12 workshops were included in this study.
Prior to our first contact with develop- ers, this study was exempted from human subjects review by the University of Roches- ter and Columbia University institutional review boards.
Survey. The online survey had 18 closed and 4 open-ended items in 3 areas: workshop objectives, features and methods (8 items); instructor selection and prepara- tion (12 items); and relevant publications and unpublished studies (2 items). The instructor
PISANI ET AL. 257
selection and preparation items were only asked for those workshops delivered by trained instructors in addition to the devel- opers. These items were not relevant for workshops instructed by developers only.
RESULTS
Survey Response
We had a 100% response rate from 11 developers for information about the 12 included workshops. One developer (McN- iel) responded to our inquiry by providing written information about his program but did not complete the survey. Respondents included workshop developers (n = 7), pro- ject managers (n = 2), and administrative support personnel (n = 2).
Narrative Overview of Included Workshops
The following section contains narra- tive descriptions of each workshop based on developer responses to an open-ended ques- tion asking what was unique about their pro- grams and on our synthesis of the published literature about each program.
The Air Force Managing Suicidal Behav- ior Project (U. S. Air Force Suicide Prevention Program: http://afspp.afms.mil). This program was developed in conjunction with a compre- hensive clinical guide commissioned by the U. S. Air Force (USAF; Oordt et al., 2005) to improve clinical responsiveness to suicide. This clinical guide was one part of a large- scale public health suicide prevention effort the USAF undertook to reduce suicide (Knox, Litts, Talcott, Feig, & Caine, 2003). This pro- gram is unique among the included workshops because it was developed to respond to a spe- cific population need as part of a one-time sui- cide prevention effort. Although the program is not publicly available, we include it in this study because of its large-scale rollout and the data gathered to support the effectiveness of a training program in changing provider atti- tudes.
Assessing and Managing Suicide Risk (AMSR; SPRC: http://www.sprc.org/training institute/index.asp). AMSR curriculum is based on recommendations from a task force of clini- cian-researchers convened in 2004 by the SPRC and the AAS (Suicide Prevention Resource Center, 2006). The workshop is organized by a sequential presentation of 24 core competencies, with a special focus on 8 competencies. The program teaches clini- cians to estimate acute and chronic risk by gathering and synthesizing information related to suicidality (past and present), mental dis- orders, mental status, and other factors known to correlate with suicide risk. The program also focuses on cultural competency in work- ing with individuals at risk for suicide.
Certification in the Chronological Assess- ment of Suicide Events (CASE; Training Institute for Suicide Assessment and Clinical Interviewing: http://www.suicideassessment.com/). This certification program offers individua- lized skill-building training based on the CASE approach (Shea, 1998), which empha- sizes comprehensive interviewing using specific techniques, including six validity techniques for uncovering assessment infor- mation about patient suicide ideation, behav- ior, intent, and plans. The certificate program uses ‘‘macrotraining’’ (Shea & Bar- ney, 2007b) and ‘‘facilic supervision’’ (Shea & Barney, 2007a), which are educational techniques designed to teach skills through practice and specific feedback. The training takes place one-on-one until the trainee qualifies for certification by demonstrating competence to the satisfaction of the trainer.
Collaborative Assessment and Manage- ment of Suicidality (CAMS; Catholic University: http://psychology.cua.edu/faculty/jobes.cfm). The CAMS program teaches a transtheoretical framework for assessing and working with suicidal individuals (Jobes, 2006; Jobes & Drozd, 2004). CAMS stresses that strong clinician-patient alliance or collaboration is key to successful treatment and provides specific guidelines for gathering risk assess- ment information. The curriculum includes a presentation about the use and empirical support from clinical research for the Suicide
258 STATE OF WORKSHOP EDUCATION
Status Form (Conrad et al., 2009; Jobes, Kahn-Greene, Greene, & Goeke-Morey, 2009; Jobes et al., 2004). The CAMS risk assessment framework draws on Shneidman’s cubic model (press, pain, and perturbation; Shneidman, 1976), as well as on knowledge of behavioral indicators of risk.
Question, Persuade, Refer, and Treat (QPRT; QPR Institute: http://www.qprinstitute. com). This program is an advanced training for mental health professionals based on QPR (Quinnett, 1995), a one-hour gate- keeper training. QPRT teaches interviewing and assessment, especially at clinical intake, and provides a tool for documenting suicide risk and assessment for patients with mental health and/or substance abuse disorders. It provides instruction for using a guided pro- tocol for interviewing and documentation. Trainees qualify for certification after pass- ing a written 25-item exam and demonstrat- ing competence through a role-play, which is rated by the instructor using a 16-item rating created by the developer for this purpose. QPRT is offered online through Eastern Washington University and in a face-to-face workshop, which is the subject of our survey.
Recognizing and Responding to Suicide Risk (RRSR; American Association of Suici- dology: http://www.suicidology.org). Like the AMSR program described earlier, this pro- gram grew out of the consensus recommen- dations of a clinician-researcher task force convened by the SPRC and the AAS in 2004 (Suicide Prevention Resource Center, 2006). The program offers 2-day workshop training plus an online pretraining module about cli- nician attitudes and approaches to suicide assessment and management. Participants must pass a multiple choice test following the online module to receive a certificate of completion for the workshop. The curricu- lum addresses the 24 core competencies identified by SPRC and AAS and task force recommendations. AAS also offers popula- tion-specific workshops: Inpatient (for hospi- tal staff), Adolescent (for youth agency staff), Veterans (for the VA), and a Spanish-lan- guage version. The program includes a medical-legal component and emphasizes
meeting legal standards of care. It uses a risk assessment framework that includes formula- tion of acute and chronic risk determination based on risk and protective factors and warning signs.
Risk Assessment Workshop (Department of Psychology, University of California San Francisco (UCSF): http://psych.ucsf.edu/faculty. aspx?id=296). This program covers assess- ment of suicide risk and risk for violence in a 5-hour workshop for psychiatric residents and other trainees at UCSF (McNiel et al., 2008). The training is based on American Psychiatric Association (APA) practice guidelines for the assessment and treatment of patients with suicidal behavior. Developed by a forensic psychologist, this workshop includes a medical-legal component and an emphasis on meeting legal standards of care and documentation. The program teaches a suicide risk framework based on Webster’s approach to assessing risk for violence (Web- ster, Douglas, Eaves, & Hart, 1997), which organizes risk markers as historical (past), clinical (present), and future (risk manage- ment). The training brings together the APA guidelines with this conceptualization of risk and teaches participants to make clinical judgments about risk severity and to develop a management plan based on anticipated future risk.
Skills-Based Training on Risk Manage- ment (STORM; The Storm Project, University of Manchester, UK: http://www.medicine. manchester.ac.uk/storm/). The STORM pro- gram was developed at the University of Manchester and has been disseminated widely in the United Kingdom. A distin- guishing feature of the program is that it uses a flexible, modular approach to skill building. Sponsoring organizations can elect to have the entire program taught over 2 days or choose from a menu of briefer modules, such as assessment, crisis management, crisis pre- vention, and self-help strategies. The pro- gram’s risk assessment framework consists of ‘‘established assessment and management methods for patients with suicidal ideation and/or feelings of hopelessness’’ (Gask, Lever-Green, & Hays, 2008).
PISANI ET AL. 259
Suicide: Understanding and Treating the Self-Destructive Processes (Glendon Association: http://www.glendon.org/). This workshop is based on the assessment and treatment approaches of Firestone and Firestone (Fire- stone, 1986; Firestone & Firestone, 1998). The curriculum includes an introduction to assessment instruments, including the Fire- stone Assessment of Suicidal Intent (FASI) and the Firestone Assessment of Self- Destructive Thoughts (FAST). The trainer uses filmed interviews with suicide attempt survivors to illustrate the conceptualization of suicidal behavior as deriving from a self- destructive ‘‘inner voice’’ or a ‘‘systematized, integrated pattern of negative thoughts, accompanied by angry affect’’ (Firestone, 1986; Firestone & Firestone, 1998). The risk assessment consists partly of understanding these self-destructive patterns. The work- shop also exposes learners to techniques of voice therapy (Firestone, 1988).
Suicide Assessment Workshop (Queen Elizabeth Psychiatric Hospital, Birmingham, UK; http://www.uhb.nhs.uk). This workshop was developed to train employees of a psy- chiatric teaching hospital in Birmingham, England (Fenwick, Vassilas, Carter, & Haque, 2004). The workshop was organized into three modules focused on assessing risk: (1) after deliberate self-harm; (2) in a hospital setting; and (3) in an outpatient setting with depression. The primary learning vehicle was a series of small-group mini-lectures fol- lowed by role-plays with professional actors. Workshop instructors provided in-vivo feed- back to participants on their assessments. This workshop was offered twice as part of a specific training initiative in 2002. Although the program is not publicly available at this time, we included it in this study because of the innovative teaching methods and evalua- tion design (see next).
Suicide Care: Aiding Life Alliances (Liv- ingWorks, Inc: http://www.livingworks.net/). Suicide Care is an advanced workshop for clinicians who have already participated in a 2-day program conducted by the program’s developers (ASIST: Applied Suicide Inter- vention Skills Training; Ramsay, Cooke, &
Lang, 1990). The program builds from ASIST’s emphasis on the human connection and empathic understanding of an indivi- dual’s reasons for suicide. The risk assess- ment framework de-emphasizes formulation or summary judgment of risk (such as high, medium, low) and instead teaches clinicians to focus on matching specific risks with specific plans. The program distinguishes among four intervention strategies—first aid, management, treatment, and therapy—and makes recommendations for clinician behav- ior and characteristics based on the concep- tualization of what at-risk persons need.
Unlocking Suicidal Secrets: New Thoughts on Old Problems in Suicide Prevention (Training Institute for Suicide Assessment and Clinical Interviewing: http://www.suicideassessment.com/). This workshop is an expanded edition of a workshop by the same developer titled, ‘‘Delicate Art of Eliciting Suicidal Ideation’’ (Shea, 1999). The program offers an over- view of suicide assessment, response, and treatment planning, and an introduction to the CASE approach to suicide assessment (Shea, 1998). The risk assessment framework emphasizes rapport building and ‘‘validity techniques’’ to elicit patient information, as well as planning and assessing ‘‘suicide events’’ (i.e., ideation, preparation, thoughts of death, and attempts) in different periods of time. The program teaches clinicians to use ‘‘matrix treatment planning’’—an evi- dence-based approach to treatment for at- risk patients designed to reduce risk for sui- cide.
Workshop Features, Format, and General Information
Table 1 provides a summary of work- shop information based on closed-ended questions from the online survey. More than 40,000 mental health professionals partici- pated in the workshops included in this study between January 2004 and August 2009. Par- ticipation in ‘‘Unlocking Suicidal Secrets’’ (provided by TISA) accounted for more than half of this participation. Workshop duration ranged from 5 to 15 hr, with a mean duration
260 STATE OF WORKSHOP EDUCATION
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PISANI ET AL. 261
of 7.5 hr (median = 6.0 hr). The most com- monly reported teaching formats were lec- ture and large group discussion, with a range of formats offered across trainings.
Domains of Competence Addressed in Learning Objectives
Developers provided written informa- tion about the learning objectives for their programs. The authors independently sorted the objectives into eight domains of compe- tence (attitudes and approach, understanding suicide, collecting accurate assessment infor- mation, formulation of risk, treatment and services planning, management of care, doc- umentation, and legal and regulatory issues). These domains correspond to those devel- oped by a SAMSHA-sponsored panel that generated a list of core competencies in the assessment and management of suicide risk (Suicide Prevention Resource Center, 2006). The independent sort yielded 89% agree- ment among authors on the domain assign- ments across programs. The authors arrived at consensus on any items on which there was less than 100% agreement.
The results of sorting each workshop’s learning objectives into competence domains appear in Table 1. Coverage of a greater number of domains does not imply a better workshop, but knowledge about which domains each program includes in its learn- ing objectives can assist clinicians or admin- istrators in selecting the workshop that best matches their needs. The domains most widely covered according to programs’ stated learning objectives were the collection of accurate assessment information (11 of 12 workshops) and formulating risk (9 of 12 workshops). The domains least widely covered were documentation (5 of 12 work- shops) and legal and regulatory issues (3 of 12 workshops).
Training and Feedback for Workshop Instructors
Table 2 summarizes information col- lected from the seven programs that reportedT
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o n
g o
in g
co n
su lt
at io
n fo
r ad
d it
io n
al fe
e S
u ic
id eC
ar e:
A id
in g
li fe
al li
an ce
s 8
A A
, F
R , T
P , M
C S
m al
l g ro
u p
d is
cu ss
io n
, la
rg e
g ro
u p
d is
cu ss
io n
7 2
5 H
an d
o u
ts
U n
lo ck
in g
su ic
id al
se cr
et s
6 C
A , F
R , T
P , D
, L
R L
ec tu
re , vi
d eo
cl ip
s 2
8 ,4
0 0
H an
d o
u ts
a A
A =
A tt
it u
d es
an d
ap p
ro ac
h ; U
S =
U n
d er
st an
d in
g su
ic id
e; C
A =
C o
ll ec
ti n
g ac
cu ra
te as
se ss
m en
t in
fo rm
at io
n ; F
R =
F o
rm u
la ti
n g
ri sk
; T
P =
T re
at m
en t
an d
se rv
ic es
p la
n n
in g
; M
C =
M an
ag em
en t
o f
ca re
; D
= D
o cu
m en
ta ti
o n
; L
R =
L eg
al an
d re
g u
la to
ry is
su es
.
262 STATE OF WORKSHOP EDUCATION
offering workshops delivered by trained instructors, in addition to the developers. The range in the number of certified instruc- tors was wide, from three additional instruc- tors to 356 instructors. The number of days of face-to-face training required also varied (from 1 half-day to more than 6 days), and developers reported other means of prepar- ing instructors in addition to their train-the- trainer programming, such as face-to-face supervision (CAMS), an option to co-train with a more experienced instructor (QPRT), and booster sessions during the first year of training (STORM). The requirements to become an instructor were fairly uniform: almost all programs required teaching and clinical experience. Four of the seven pro- grams required instructors to hold a clinical licensure, and the same number of programs required a master’s degree or higher.
The programs reported providing feedback to instructors about their perfor- mance mostly through satisfaction surveys. Five of seven programs reported that they ‘‘always’’ provide satisfaction survey data to instructors; one program reported it ‘‘usu- ally’’ provides this form of feedback; and another reported it ‘‘occasionally’’ does. None of the programs routinely provide feedback to instructors based on live or vid- eotaped observation of workshop delivery; three of the seven reported that they occa- sionally provide observation-based feedback. Program leaders reported using other forms of feedback, such as telephone or peer super- vision, occasionally or as needed.
EVALUATION STUDIES
Seven of the 12 programs have pub- lished evaluation studies relating to their workshop or their approach to risk assess- ment. A summary of these studies is presented in Table 3. Most of these studies examine the effect of the training on the knowledge, skills, or attitudes of participants. Four studies examined the validity and utility of an assess- ment tool. Two studies examined outcomes on suicidality in the target population.
Studies that Evaluate Participant Outcomes (Knowledge, Skills, and Attitudes)
Studies that evaluate the efficacy of the training in improving participants’ knowl- edge, skills, and attitudes include: (1) studies that evaluate one of the 12 workshops for mental health professionals that are the focus of the present review; and (2) studies that evaluate a workshop that is related to one of the 12 workshops we focus on, but which tar- get a population other than mental health professionals, such as community members or gatekeepers. We report here on studies about related workshops because workshops in both categories share a common training model and approach to suicide. Thus, evidence about the efficacy of a related com- munity-targeted workshop is relevant to assessing the evidence base of the workshop for mental health professionals.
Workshops that Target Mental Health Professionals. There are published studies on 4 of 12 workshops that were the focus of our developer survey. Oordt, Jobes, Fonseca, and Schmidt (2009) demonstrated that 82 Air Force clinicians’ confidence and attitudes toward recommended practice behaviors improved immediately and were maintained 6 months after 12 hours of training and exposure to a comprehensive practice guide on assessing and managing suicidal behavior. McNiel et al. (2008) found that 43 psychiatry residents who participated in five hours of concentrated risk assessment training demonstrated improvements in self-efficacy and in the objectively rated quality of written assessments immediately following the train- ing. These improvements were greater for a trained group than for a comparison group. Gask, Dixon, Morriss, Appleby, and Green (2006) showed that the attitudes and confidence of 438 mental health staff who participated in an 8-hour STORM training improved over baseline immediately after training. This improvement was sustained among 143 subjects who were surveyed 4 months later. However, improvement in interview skills measured immediately after
PISANI ET AL. 263
T A
B L
E 2
In st
ru ct
or C
h ar
ac te
ri st
ic s
fo r
W or
k sh
op s
th at
C er
ti fy
N on
de v el
op er
In st
ru ct
or s
P ro
g ra
m n
am e
# o
f ce
rt ifi
ed in
st ru
ct o
rs T
ra in
in g
in st
ru ct
o rs
re ce
iv e
to d
el iv
er w
o rk
sh o
p
M as
te r’
s d
eg re
e re
q u
ir ed
T ea
ch in
g ex
p er
ie n
ce re
q u
ir ed
C li
n ic
al ex
p er
ie n
ce re
q u
ir ed
L ic
en su
re re
q u
ir ed
A ss
es si
n g
an d
m an
ag in
g su
ic id
e ri
sk 6
2 3
-d ay
tr ai
n -t
h e-
tr ai
n er
p ro
g ra
m w
it h
m as
te r
tr ai
n er
Y es
Y es
Y es
Y es
C o
ll ab
o ra
ti ve
as se
ss m
en t
an d
m an
ag em
en t
o f
su ic
id al
it y
(C A
M S
)
3 M
ee ti
n g
s w
it h
d ev
el o
p er
(t ra
in er
s ar
e g
ra d
u at
e st
u d
en ts
)
N o
Y es
Y es
N o
Q u
es ti
o n
, p
er su
ad e,
re fe
r, tr
ea t
(Q P
R T
) 1
2 9
1 -d
ay co
-t ra
in in
g w
it h
ad va
n ce
d tr
ai n
er Y
es Y
es Y
es Y
es
R ec
o g
n iz
in g
an d
re sp
o n
d in
g to
su ic
id e
ri sk
: E
ss en
ti al
sk il
ls fo
r cl
in ic
ia n
s (R
R S
R )
1 2
5 -d
ay tr
ai n
-t h
e- tr
ai n
er p
ro g
ra m
w it
h m
as te
r tr
ai n
er Y
es Y
es Y
es Y
es
S k il
ls -b
as ed
tr ai
n in
g o
n ri
sk m
an ag
em en
t (S
T O
R M
) 3
5 6
4 -d
ay tr
ai n
-t h
e- tr
ai n
er p
ro g
ra m
, 3
fa ce
-t o
-f ac
e su
p p
o rt
se ss
io n
s d
u ri
n g
fi rs
t y ea
r
N o
Y es
N o
N o
S u
ic id
e ca
re : A
id in
g li
fe al
li an
ce s
1 0
3 -d
ay tr
ai n
-t h
e- tr
ai n
er p
ro g
ra m
, in
ad d
it io
n to
5 -d
ay p
ro g
ra m
to b
ec o
m e
A S
IS T
tr ai
n er
Y es
Y es
Y es
Y es
S u
ic id
e as
se ss
m en
t w
o rk
sh o
p 8
H al
f- d
ay tr
ai n
in g
w it
h d
ev el
o p
er s
N o
N o
Y es
Y es
264 STATE OF WORKSHOP EDUCATION
T A
B L
E 3
E v al
u at
io n
S tu
di es
P ro
g ra
m S
o u
rc e
S am
p le
D es
ig n
an d
ta rg
et o
u tc
o m
e O
u tc
o m
e
S tu
d ie
s e v a lu
a ti
n g
p a rt
ic ip
a n
t o
u tc
o m
e s
(k n
o w
le d
g e , sk
il ls
, a n
d a tt
it u
d e s)
E v id
en ce
fr om
st u
di es
ab ou
t th
e w
or k sh
op s
th at
ta rg
et m
en ta
l h ea
lt h
pr of
es si
on al
s A
ir F
o rc
e (O
o rd
t et
al .,
2 0
0 9
) 8
2 ac
ti ve
d u
ty A
ir F
o rc
e m
en ta
l h
ea lt
h p
ro fe
ss io
n al
s
P re
– p
o st
-6 -m
o n
th f/
u se
lf -r
ep o
rt ed
co n
fi d
en ce
, b
el ie
fs , an
d cl
in ic
p o
li ci
es an
d p
ro ce
d u
re s
Im p
ro ve
m en
t p
re – p
o st
in so
m e
as p
ec ts
o f
co n
fi d
en ce
an d
b el
ie fs
; in
co n
cl u
si ve
re su
lt s
ab o
u t
th e
im p
ac t
o f
tr ai
n in
g o
n p
o li
ci es
an d
p ro
ce d
u re
s R
is k
as se
ss m
en t
w o
rk sh
o p
(M cN
ie l
et al
., 2
0 0
8 )
4 5
p sy
ch ia
tr y
an d
p sy
ch o
lo g
y tr
ai n
ee s
Im m
ed ia
te p
re – p
o st
se lf
-r ep
o rt
an d
o b
je ct
iv el
y ra
te d
d o
cu m
en ta
ti o
n sa
m p
le
Im p
ro ve
m en
t in
se lf
-r ep
o rt
ed co
n fi
d en
ce an
d o
b je
ct iv
el y
ra te
d d
o cu
m en
ta ti
o n
sk il
l co
m p
ar ed
w it
h b
as el
in e
an d
to a
co m
p ar
is o
n g
ro u
p S
T O
R M
(G as
k et
al .,
2 0
0 6
) 4
5 8
st af
f in
th re
e m
en ta
l h
ea lt
h se
rv ic
es P
re – p
o st
se lf
-r ep
o rt
w it
h w
h o
le sa
m p
le (i
m m
ed ia
te an
d 4
m o
n th
f/ u
); P
re – p
o st
sk il
l ac
q u
is it
io n
ro le
-p la
y at
4 m
o n
th f/
u w
it h
a 1
7 -v
o lu
n te
er su
b se
t
Im p
ro ve
m en
t in
at ti
tu d
es an
d co
n fi
d en
ce (w
h o
le sa
m p
le );
n o
ch an
g e
in sk
il ls
d em
o n
st ra
te d
in ro
le -p
la y
(s u
b se
t)
S u
ic id
e as
se ss
m en
t w
o rk
sh o
p (F
en w
ic k
et al
., 2
0 0
4 )
8 9
m en
ta l
h ea
lt h
p ro
fe ss
io n
al s
an d
2 0
o th
er h
ea lt
h p
ro fe
ss io
n al
s
F u
ll -d
ay vs
. h
al f-
d ay
w o
rk sh
o p
; P
re – p
o st
-2 -m
o n
th f/
u Im
p ro
ve d
co n
fi d
en ce
in b
o th
g ro
u p
s, su
st ai
n ed
at f/
u
E v id
en ce
fr om
st u
di es
ab ou
t re
la te
d w
or k sh
op s
th at
ta rg
et co
m m
u n
it y
m em
be rs
or ga
te k ee
pe rs
S u
ic id
e ca
re (S
tu d
ie s
ab o
u t
re la
te d
co m
m u
n it
y w
o rk
sh o
p ,
A S
IS T
)
(G u
tt o
rm se
n et
al .,
2 0
0 3
) 7
6 m
ed ic
al st
u d
en ts
P o
st -t
ra in
in g
fo cu
s g
ro u
p in
te rv
ie w
s w
it h
au th
o rs
S tu
d en
t re
p o
rt s
o f
m o
re co
n fi
d en
ce an
d b
et te
r sk
il ls
(P ea
rc e
et al
., 2
0 0
3 )
4 2
u n
iv er
si ty
st u
d en
ts P
re -t
es t–
p o
st -t
es t
se lf
-r ep
o rt
; 2
m o
n th
f/ u
(2 7
p ar
ti ci
p an
ts )
w it
h 2
-i te
m se
lf -r
ep o
rt
P o
st -t
ra in
in g
: Im
p ro
ve m
en ts
in at
ti tu
d es
, n
o rm
s, p
er ce
iv ed
b eh
av io
ra l
co n
tr o
l, se
lf -e
ffi ca
cy ,
m en
ta l
h ea
lt h
li te
ra cy
, an
d in
te n
ti o
n to
in te
rv en
e p o st
-t ra
in in
g . N
o ch
an g es
in co
n n
ec te
d n
es s
o r
so ci
al d
is ta
n ce
. F
/u : D
if fi
cu lt
to in
te rp
re t
d u
e to
sm al
l n
u m
b er
o f
f/ u
p ar
ti ci
p an
ts
PISANI ET AL. 265
T A
B L
E 3
(C on
ti n u ed
)
P ro
g ra
m S
o u
rc e
S am
p le
D es
ig n
an d
ta rg
et o
u tc
o m
e O
u tc
o m
e
(T ie
rn ey
, 1
9 9
4 )
S tu
d y
1 (S
k il
ls ):
3 6
co m
m u
n it
y p
ar ti
ci p
an ts
(1 9
p re
– p
o st
; 1
7 p
o st
o n
ly )
P re
– p
o st
o b
se rv
at io
n al
ra ti
n g
o f
sk il
ls in
ro le
-p la
y ;
S el
f- re
p o
rt se
le ct
io n
o f
re sp
o n
se to
vi g
n et
te (S
IR I)
P re
– p
o st
im p
ro ve
m en
t in
o b
se rv
at io
n al
ra ti
n g
s o
f in
te rv
en ti
o n
sk il
l; n
o ch
an g
e o
n S
IR I
S tu
d y
2 (A
tt it
u d
es ):
1 5
4 co
m m
u n
it y
p ar
ti ci
p an
ts in
in te
rv en
ti o
n g
ro u
p ,
2 0
u n
iv er
si ty
st u
d en
ts ‘‘
n o
n eq
u iv
al en
t co
n tr
o ls
’’
P re
– p
o st
se lf
-r ep
o rt
k n
o w
le d
g e
an d
at ti
tu d
es ; co
m p
ar is
o n
w it
h n
o n
eq u
iv al
en t
co n
tr o
l g
ro u
p
S m
al l
p re
– p
o st
im p
ro ve
m en
ts in
k n
o w
le d
g e
an d
at ti
tu d
es ; n
o d
if fe
re n
ce s
b et
w ee
n in
te rv
en ti
o n
an d
n o
n eq
u iv
al en
t co
n tr
o ls
Q P
R T
(S tu
d ie
s ab
o u
t re
la te
d g
at ek
ee p
er w
o rk
sh o
p , Q
P R
)
(C ro
ss et
al .,
2 0
0 7
) 7
6 n
o n
cl in
ic ia
n em
p lo
y ee
s in
u n
iv er
si ty
h o
sp it
al se
tt in
g
P re
– p
o st
se lf
-r ep
o rt
o f
d ec
la ra
ti ve
k n
o w
le d
g e
an d
se lf
-e ffi
ca cy
; p
o st
an d
f/ u
o b
se rv
at io
n al
ra ti
n g
o f
g at
ek ee
p er
sk il
ls in
su b
se t
o f
su b
je ct
s u
si n
g st
an d
ar d
iz ed
p at
ie n
t m
et h
o d
; d
if fu
si o
n o
f tr
ai n
in g
in fo
rm at
io n
at f/
u
S ig
n ifi
ca n
t in
cr ea
se in
k n
o w
le d
g e
an d
se lf
-e ffi
ca cy
fr o
m p
re -
to p
o st
-t es
ti n
g ; 5
5 %
o f
p ar
ti ci
p an
ts d
em o
n st
ra te
d ad
eq u
at e
g at
ek ee
p er
sk il
ls ; p
ar ti
ci p
an ts
d if
fu se
d th
e tr
ai n
in g
in fo
rm at
io n
to fa
m il
y , fr
ie n
d s,
an d
co -w
o rk
er s
(C ro
ss et
al .,
2 0
1 0
) 5
0 ra
n d
o m
ly se
le ct
ed em
p lo
y ee
s at
5 A
m er
ic an
u n
iv er
si ti
es (c
am p
u s–
re si
d en
ce as
si st
an ts
, fa
cu lt
y ,
fa ci
li ti
es w
o rk
er s,
st u
d en
t af
fa ir
s st
af f,
an d
co ac
h es
)
P re
-t ra
in in
g va
ri ab
le s
(e .g
., p
er so
n al
it y , p
re vi
o u
s ex
p er
ie n
ce ),
k n
o w
le d
g e
ab o
u t
su ic
id e,
an d
p er
ce iv
ed ef
fi ca
cy fo
r in
te rv
en in
g w
it h
su ic
id al
in d
iv id
u al
s; p
o st
k n
o w
le d
g e
& p
er ce
iv ed
ef fi
ca cy
; P
re – p
o st
o b
se rv
at io
n al
ra ti
n g
o f
g at
ek ee
p er
sk il
ls u
si n
g st
an d
ar d
iz ed
p at
ie n
t m
et h
o d
S ig
n ifi
ca n
tl y
h ig
h er
p er
ce iv
ed ef
fi ca
cy an
d k n
o w
le d
g e
p o
st -
tr ai
n in
g ; si
g n
ifi ca
n tl
y im
p ro
ve d
o b
se rv
ed su
ic id
e sp
ec ifi
c sk
il ls
at p
o st
-t es
t; n
o si
g n
ifi ca
n t
ch an
g e
in g
en er
al sk
il ls
(e .g
., ac
ti ve
li st
en in
g );
5 4
% d
em o
n st
ra te
d ad
eq u
at e
g at
ek ee
p er
sk il
ls at
p o
st -t
ra in
in g
; p
re -t
ra in
in g
va ri
ab le
s d
id n
o t
p re
d ic
t in
cr ea
se d
sk il
ls
266 STATE OF WORKSHOP EDUCATION
T A
B L
E 3
(C on
ti n u ed
)
P ro
g ra
m S
o u
rc e
S am
p le
D es
ig n
an d
ta rg
et o
u tc
o m
e O
u tc
o m
e
(M at
th ie
u et
al .,
2 0
0 8
) 6
0 2
V A
cl in
ic al
an d
n o
n cl
in ic
al st
af f
fr o
m 2
0 9
co m
m u
n it
y co
u n
se li
n g
ce n
te rs
P re
– p
o st
se lf
-r ep
o rt
o f
d ec
la ra
ti ve
k n
o w
le d
g e,
se lf
-e ffi
ca cy
, an
d p
o st
se lf
-r ep
o rt
o f
ro le
-p la
y p
ra ct
ic e
b eh
av io
rs
S ig
n ifi
ca n
t in
cr ea
se in
k n
o w
le d
g e
an d
se lf
-e ffi
ca cy
p o
st as
se ss
m en
t, w
it h
n o
n cl
in ic
ia n
s sh
o w
in g
la rg
er ef
fe ct
si ze
s
(R ei
s &
C o
rn el
l, 2
0 0
8 )
7 3
sc h
o o
l co
u n
se lo
rs ,
1 6
5 te
ac h
er s
(t ra
in ed
), 7
4 co
u n
se lo
rs , an
d 9
8 te
ac h
er s
(u n
tr ai
n ed
)
T ra
in ed
vs . u
n tr
ai n
ed co
m p
ar is
o n
g ro
u p
G re
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m o
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te r
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g (T
o m
p k in
s &
W it
t, 2
0 0
9 )
1 2
2 co
ll eg
e re
si d
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ad vi
so rs
, 8
6 n
o n
tr ai
n ed
co n
tr o
ls
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– p
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f/ u
; se
lf -r
ep o
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k n
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m p
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w it
h n
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tr ai
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co n
tr o
ls
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ro ve
m en
ts in
k n
o w
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g e
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at ti
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es am
o n
g p
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ci p
an ts
an d
am o
n g
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(W y m
an et
al .,
2 0
0 8
) G
ro u
p -b
as ed
ra n
d o
m iz
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ia l
w it
h 3
2 sc
h o
o ls
, w
it h
st ra
ti fi
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m p
le (n
= 2
4 9
) o
f st
af f
R C
T ; se
lf -r
ep o
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d ec
la ra
ti ve
k n
o w
le d
g e,
ap p
ra is
al s,
an d
g at
ek ee
p er
b eh
av io
rs at
1 -y
ea r
f/ u
In cr
ea se
s in
k n
o w
le d
g e
an d
ap p
ra is
al s
p o
st -t
ra in
in g
an d
at f/
u ; m
ar g
in al
d if
fe re
n ce
in as
k in
g st
u d
en ts
ab o
u t
su ic
id e,
p ri
m ar
il y
am o
n g
st af
f en
g ag
ed in
th es
e b
eh av
io rs
at b
as el
in e
R R
S R
(S tu
d y
ab o
u t
re la
te d
g at
ek ee
p er
w o
rk sh
o p
, R
R S
R -P
C )
(W in
te rs
te en
, 2
0 1
0 ).
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ic al
p ro
vi d
er s
in th
re e
p ri
m ar
y ca
re p
ra ct
ic es
P re
– p
o st
m ed
ic al
re co
rd re
vi ew
o f
n u
m b
er o
f ad
o le
sc en
ts sc
re en
ed an
d d
et ec
te d
as su
ic id
al af
te r
tr ai
n in
g an
d el
ec tr
o n
ic p
ro m
p ts
fo r
sc re
en in
g
S u
b st
an ti
al in
cr ea
se in
sc re
en in
g an
d d
et ec
ti o
n in
al l
th re
e cl
in ic
s af
te r
R R
S R
-P C
tr ai
n in
g an
d el
ec tr
o n
ic sc
re en
in g
p ro
m p
ts w
er e
im p
le m
en te
d
PISANI ET AL. 267
T A
B L
E 3
(C on
ti n u ed
)
P ro
g ra
m S
o u
rc e
S am
p le
D es
ig n
an d
ta rg
et o
u tc
o m
e O
u tc
o m
e
S T
O R
M (S
tu d
ie s
ab o
u t
re la
te d
S T
O R
M w
o rk
sh o
p fo
r co
m m
u n
it y –
g at
ek ee
p er
s)
(A p
p le
b y
et al
., 2
0 0
0 )
3 5
9 h
ea lt
h p
ro fe
ss io
n al
s o
ff er
ed tr
ai n
in g
in a
re g
io n
al in
it ia
ti ve
; 1
6 7
h ea
lt h
p ro
fe ss
io n
al s
p ar
ti ci
p at
ed (9
5 p
ri m
ar y
ca re
, 2
1 em
er g
en cy
m ed
ic in
e, 5
1 m
en ta
l h
ea lt
h )
R at
e o
f at
te n
d an
ce ; im
m ed
ia te
p re
– p
o st
se lf
-r ep
o rt
; P
re – p
o st
sk il
l (2
ac q
u is
it io
n ro
le -p
la y s
w it
h a
2 8
-v o
lu n
te er
su b
se t
at 2
m o
n th
f/ u
)
4 7
% o
f el
ig ib
le p
ro fe
ss io
n al
s p
ar ti
ci p
at ed
; im
p ro
ve m
en ts
in co
n fi
d en
ce an
d at
ti tu
d es
; n
o n
- si
g n
ifi ca
n t
im p
ro ve
m en
ts in
sk il
l in
ro le
-p la
y fo
r h
ea lt
h p
ro fe
ss -
io n
al s
(n =
1 4
), b
u t
n o
t m
en ta
l h
ea lt
h p
ro fe
ss io
n al
s (n
= 1
4 )
w h
o vo
lu n
te er
ed to
d o
ro le
-p la
y (H
ay es
et al
., 2
0 0
8 )
1 6
1 p
ri so
n st
af f
P re
– p
o st
se lf
-r ep
o rt
(I m
m ed
ia te
an d
6 m
o n
th f/
u )
Im p
ro ve
m en
t in
k n
o w
le d
g e,
at ti
tu d
es , an
d co
n fi
d en
ce im
m ed
ia te
ly af
te r
an d
at 6
m o
n th
s S
tu d
ie s
th a t
e v a lu
a te
th e
a p
p ro
a c h
to a ss
e ss
m e n
t E
v id
en ce
fr om
st u
di es
ab ou
t th
e w
or k sh
op th
at ta
rg et
s m
en ta
l h ea
lt h
pr of
es si
on al
s C
A M
S (C
o n
ra d
et al
., 2
0 0
9 )
1 4
9 p
sy ch
ia tr
ic in
p at
ie n
ts V
al id
it y
an d
re li
ab il
it y
st u
d y ;
P at
ie n
t- co
m p
le te
d S
S F
o n
ad m
is si
o n
an d
4 8
– 7
2 h
r la
te r
T w
o -f
ac to
r so
lu ti
o n
: ch
ro n
ic an
d ac
u te
; g
o o
d co
n ve
rg en
t an
d cr
it er
io n
va li
d it
y ; m
o d
er at
e te
st -r
e te
st re
li ab
il it
y (J
o b
es et
al .,
2 0
0 9
) 9
2 su
ic id
al p
at ie
n ts
in u
n iv
er si
ty co
u n
se li
n g
ce n
te r
P re
d ic
ti o
n o
f se
ss io
n -t
o -s
es si
o n
ch an
g e
in su
ic id
al id
ea ti
o n
fr o
m S
S F
P at
ie n
ts im
p ro
ve d
; S
S F
ra ti
n g
s o
f o
ve ra
ll ri
sk m
o d
er at
ed se
ss io
n -t
o -s
es si
o n
ch an
g e;
S S
F h
o p
el es
sn es
s an
d se
lf -h
at e
m o
d er
at ed
p at
ie n
t ra
ti n
g s
o f
su ic
id al
th o
u g
h ts
o ve
r co
u rs
e o
f tr
ea tm
en t
(J o
b es
et al
., 1
9 9
7 )
1 0
6 su
ic id
al p
at ie
n ts
in u
n iv
er si
ty co
u n
se li
n g
ce n
te r
se en
o ve
r 5
-y ea
r p
er io
d
S tu
d y
1 : V
al id
it y
an d
re li
ab il
it y
st u
d y
o f
S S
F S
tu d
y 2
: C
o rr
el at
io n
st u
d y
o f
p re
tr ea
tm en
t se
lf -r
ep o
rt an
d tr
ea tm
en t
o u
tc o
m e
p at
te rn
s
S tu
d y
1 : co
n ve
rg en
t va
li d
it y ,
st ro
n g
cr it
er io
n -p
re d
ic ti
o n
va li
d it
y , an
d m
o d
er at
e te
st -r
et es
t re
li ab
il it
y ; S
tu d
y 2
: C
li en
t re
p o
rt o
n S
S F
p re
d ic
ts n
o n
-r es
p o
n se
to tr
ea tm
en t
268 STATE OF WORKSHOP EDUCATION
T A
B L
E 3
(C on
ti n u ed
)
P ro
g ra
m S
o u
rc e
S am
p le
D es
ig n
an d
ta rg
et o
u tc
o m
e O
u tc
o m
e
(J o
b es
et al
., 2
0 0
4 )
1 1
9 co
ll eg
e st
u d
en ts
, 3
3 U
S A
F p
er so
n n
el ; al
l w
it h
su ic
id al
id ea
ti o
n
Q u
al it
at iv
e so
rt o
f o
p en
-e n
d ed
w ri
tt en
re sp
o n
se s
to S
S F
p ro
m p
ts
R es
p o
n se
s re
li ab
ly ca
te g
o ri
ze d
as re
la ti
o n
al , ro
le re
sp o
n si
b il
it y ,
se lf
, an
d u
n p
le as
an t
in te
rn al
st at
es S
tu d
ie s
th a t
e v a lu
a te
p a ti
e n
t o
r p
o p
u la
ti o
n o
u tc
o m
e s
E v id
en ce
fr om
a st
u dy
ab ou
t th
e w
or k sh
op th
at ta
rg et
s m
en ta
l h ea
lt h
pr of
es si
on al
s C
A M
S (J
o b
es et
al .,
2 0
0 5
) 2
5 C
A M
S , 3
0 T
A U
p at
ie n
ts in
u n
iv er
si ty
co u
n se
li n
g ce
n te
r
R et
ro sp
ec ti
ve o
u tc
o m
e st
u d
y C
A M
S tr
ea tm
en t
g ro
u p
re so
lv ed
su ic
id al
it y
m o
re q
u ic
k ly
an d
h ad
le ss
m ed
ic al
h ea
lt h
ca re
u ti
li za
ti o
n th
an T
A U
in 6
m o
n th
s af
te r
st ar
t o
f tr
ea tm
en t
E v id
en ce
fr om
a st
u dy
ab ou
t a
re la
te d
w or
k sh
op th
at ta
rg et
s co
m m
u n
it y
m em
be rs
or ga
te k ee
pe rs
S T
O R
M (S
tu d
y ab
o u
t re
la te
d S
T O
R M
w o
rk sh
o p
fo r
co m
m u
n it
y –
g at
ek ee
p er
s)
(M o
rr is
s et
al .,
2 0
0 5
) P
o p
u la
ti o
n fo
r a
d is
tr ic
t an
d re
g io
n in
E n
g la
n d
b ef
o re
an d
af te
r tr
ai n
in g
in te
rv en
ti o
n
P re
– p
o st
su ic
id e
ra te
s in
d is
tr ic
t w
h er
e tr
ai n
in g
w as
d el
iv er
ed to
1 6
7 h
ea lt
h p
ro fe
ss io
n al
s (s
ee A
p p
le b
y et
al .,
2 0
0 0
)
N o
ch an
g e
in su
ic id
e ra
te
S S
F =
S u
ic id
e S
ta tu
s F
o rm
; f/
u =
fo ll
o w
-u p
; T
A U
= tr
ea tm
en t
as u
su al
.
PISANI ET AL. 269
training via 15-minute role-plays among 17 participants was not sustained after 4 months. Fenwick et al. (2004) conducted a compari- son between a 6-hour suicide assessment workshop that had multiple active learning components and a 3-hour program consisting mostly of lecture and paired participant dis- cussion. Participants in both groups gained confidence from the trainings, and gains were sustained at 2-month follow-up.
Workshops that Target Community Mem- bers or Gatekeepers. Four of the 12 develop- ers surveyed in this study (Quinnett–QPRT, LivingWorks–Suicide Care, and Gask–STORM) have disseminated programs for community gatekeepers or general health professionals. Key results from evaluations of these work- shops with community or general health (nonmental health) samples are as follows.
QPRT is an advanced workshop for mental health professionals based on QPR, a brief gatekeeper training that has been widely disseminated in the United States Post-train- ing gains in knowledge, self-efficacy, and atti- tudes have been demonstrated in multiple community samples (Capp, Deane, & Lam- bert, 2001; Cross, Matthieu, Cerel, & Knox, 2007; Matthieu, Cross, Batres, Flora, & Knox, 2008; Reis & Cornell, 2008; Tompkins & Witt, 2009). In one sample (50 university employees), observed interview skills im- proved after QPR training (Cross, Matthieu, Lezine, & Knox, 2010). In a randomized con- trolled trial of QPR with staff from 32 public high schools, QPR-trained staff showed sig- nificant increases in knowledge and attitudes after training but only marginal differences in reported behavior in asking students about suicide were reported at 1-year follow-up (Wyman et al., 2008).
The American Association of Suicidol- ogy has developed an abbreviated (90-min) version of RRSR to train primary profession- als (RRSR-PC). RRSR-PC, Youth Version was used in conjunction with the implemen- tation and evaluation of a two-question suicide risk prompt that was electronically delivered to physicians in three primary care practices during medical visits with adoles- cents. The number of adolescents screened
and detected increased substantially in all three clinics after clinicians received training and electronic prompts (Wintersteen, 2010).
Suicide Care is an advanced workshop for mental health professionals based on ASIST, an internationally disseminated program designed as ‘‘suicide first aid.’’ Post- training changes in suicide-related knowl- edge, attitudes, and confidence have been documented in a focus group study with med- ical students (Guttormsen, Hoifodt, Silva, & Burkeland, 2003) and in a self-report study with university students (Pearce, Rickwood, & Beaton, 2003). A small sample of commu- nity participants showed substantial pre–post improvement in skill measured by observa- tional ratings of a role-play (Tierney, 1994).
As described earlier, STORM has a flexible modular program that can be adapted to train a range of professional and nonprofessional groups. Regarding commu- nity groups, post-training improvements in knowledge, confidence, and attitudes have been achieved with prison staff (Hayes, Shaw, Lever-Green, Parker, & Gask, 2008) and with a multidisciplinary group of health professionals (Appleby et al., 2000). Participants in the latter study were mostly general health professionals, but a third of the participants were mental health profes- sionals. This study found no significant changes in skill demonstration among a small subset of general and specialty mental health professionals who participated in a role-play demonstration.
Studies that Evaluate the Assessment Component of a Workshop
Studies by Jobes and colleagues have demonstrated the convergent, criterion, and predictive validity of the Suicide Status Form (SSF), a patient assessment tool at the heart of the approach presented in the workshop. Patient responses on the SSF predict session- to-session change in suicidal ideation (Jobes et al., 2009) and various treatment outcome patterns (Conrad et al., 2009; Jobes, Jacoby, Cimbolic, & Hustead, 1997; Jobes et al., 2004).
270 STATE OF WORKSHOP EDUCATION
Studies that Evaluate Patient or Population Outcomes
There are two studies that examined outcomes at the patient or population level. In a retrospective study of university coun- seling clients, 25 clients treated with the CAMS approach resolved suicidal ideation more quickly than 30 clients who experi- enced usual care psychotherapy (Jobes, Wong, Conrad, Drozd, & Neal-Walden, 2005). The practitioners in this study were not trained with the CAMS workshop but had more extensive training in the CAMS approach. Thus, this study provides evidence for the approach advocated by the CAMS workshop, but does not address the efficacy of the workshop as a stand-alone educational offering. The second study relates to STORM. STORM is the only program in our sample that has been the subject of a study evaluating population-level changes in response to the educational intervention. Morriss, Gask, Webb, Dixon, & Appleby, (2005) found no change in the suicide rate in a region in which a large proportion of health professionals were trained with STORM.
DISCUSSION
This article describes the state of workshop education for mental health pro- fessionals in the assessment and management of suicide risk. We applied rigorous eligibil- ity criteria to select in-person workshops that (1) target mental health professionals; (2) aim to promote general clinical competence in the assessment and management of suicide risk; and (3) have at least one published, peer-reviewed article describing or evaluat- ing the training or model on which it is based. Our study is the first to provide a cross-program description of the objectives and methods of the clinician-targeted work- shops; characterize the training, qualifica- tions, and feedback for the trainers who deliver the workshops; and review published studies about training outcomes.
We surveyed developers of the 12 pro- grams that met the criteria and discovered that these workshops cover a wide range of learning objectives, with the heaviest focus on assessment and formulation of suicide risk. Workshops that emphasized documentation and managing care in their written learning objectives were less common. Thousands of clinicians in the mental health workforce attend workshop trainings each year and more than 40,000 mental health professionals have participated in these 12 workshops. Half of the workshops included in our study have been delivered by program developers only; the other half are delivered by other trained instructors as well as by the developers. These additional instructors typically have at least a master’s degree, clinical experience, and licensure, and some have past teaching experi- ence. They generally receive one to two days of initial training and minimal ongoing feed- back, which mostly consists of results from satisfaction surveys. None of the programs reported routinely providing expert feedback based on observed performance.
The content provided to clinician participants in these workshops has strong face validity and bears the mark of expert clinician-developers. The programs are ‘‘evidence-based’’ in the sense that some of the content draws from clinical epidemiology and treatment research. Several of the work- shops have grown out of mature treatment or prevention models, which have demonstrated efficacy with respect to improving participant knowledge and attitudes. Many use innova- tive and promising pedagogical techniques. One of the authors (ARP) attended most of the publically available workshops examined in this study and found them practical and engaging. In short, these workshops gener- ally convey the best available recommenda- tions for clinical practice, often in innovative ways. Furthermore, some of the programs have begun to take steps to assure that partic- ipants have learned what is taught: RRSR requires participants to pass a multiple- choice test, and QPRT and CASE require role-played demonstration of specific inter- viewing skills. Nevertheless, there is an
PISANI ET AL. 271
urgency to evaluate the impact that training has on the care mental health professionals provide and the outcomes they achieve.
Our project revealed that research documenting real-world outcomes from these workshops for mental health profes- sionals is limited. Studies up to this point have established that clinician knowledge and attitudes improve in response to train- ing, but the evidence with respect to clinical skill comes from just two studies, making it difficult to draw conclusions. McNiel and colleagues’ (2008) workshop produced a meaningful post-training improvement in vignette-based written risk assessment. Gask and colleagues (2006) found that mental health professionals’ interview skills improved in the short-term, but the effect did not persist in a small follow-up group. We found no studies addressing the impact of workshop training on observed practice with real patients or on outcomes clinicians achieve with patients after participating in training. Although the framework taught in the CAMS workshop has evidence to support its efficacy with patients, this evidence can- not be extrapolated to the workshop because the clinicians providing treatment in the stu- dies we reviewed were not trained via a work- shop, but rather trained extensively in CAMS at the home institution of the developer.
Thus, based on the evidence available at this time, we can conclude that workshops provide an effective means for transferring knowledge and shifting attitudes, but not nec- essarily skills. Until we have more evidence that workshops improve skill and impact patient outcomes, clinicians and administra- tors can think of workshops as serving a valu- able role in clinician education (transferring knowledge and attitudes, introducing skills), but should recognize that workshops have not yet been demonstrated to improve the clinical care of suicidal patients.
Limitations
We focused on one type of educational opportunity for practicing clinicians: in-per- son workshops that purport to strengthen
general, transtheoretical competency. These workshops do not represent the full range of clinical education that is available for profes- sionals who wish to improve their ability to work with suicidal individuals. For example, we did not focus on workshops for clinicians seeking specific expertise in a manualized treatment or techniques for working with suicidal individuals. We also did not catalog education that is taking place in other venues, such as ad hoc employer in-services, clinical supervision, online courses, and professional journal articles. Thus, this article contributes knowledge about a significant, but limited, part of the spectrum of clinical training oppor- tunities. Studies of clinical education in spe- cific treatments and data through other venues are needed to evaluate the full range of clinical education in the assessment, management, and treatment of patients at risk for suicide.
We relied upon a relatively brief survey to minimize participant burden and maximize participation. While trying to be as comprehensive as possible, our survey may not have captured all domains relevant to describing the state of workshop education.
Finally, we gathered some of our data from developers via self-report. A vested interest in their program could bias develop- ers’ reporting of the number of clinicians trained, the qualifications of trainers, and support trainers receive. Nevertheless, most of the information included in this article is based on publically available material.
Future Directions
Our study on the current state of work- shop education in the assessment and manage- ment of suicide risk suggests several specific areas for future development and study. First, workshop developers should focus effort on factors that influence the implementation of knowledge, attitudes, and skills gained in workshops. Follow-up sessions, online refreshers, and special training for supervisors and administrators may be necessary for workshops to have an effect on patient care. Educational developers should thus consider collaborating with implementation scientists,
272 STATE OF WORKSHOP EDUCATION
whose field of study specifically includes designing interventions to improve implemen- tation of skills and practices into service settings (Proctor et al., 2009).
Second, half of the workshops in this study are disseminated using instructors who are trained by developers or by master train- ers to deliver the workshop. While this ‘‘train-the-trainer’’ model is efficient and often necessary, the ability of trainers to present the workshops with fidelity and com- petence is a potential constraint to effective- ness. Research on the education and support process for instructors—including the role of instructor selection, feedback, and sup- port—is needed to determine how to pro- mote successful transfer to training from master trainers to instructors.
Third, despite the high prevalence of suicidal ideation and behavior among patients receiving mental health treatment, there are very limited data about current practices and needs in the mental health workforce. We lack basic information about how (and how often) clinicians elicit, explore, and respond to information about suicidal thinking, plans, and behavior. Scientific knowledge about usual care can help focus educational efforts on the areas most needing
improvement and enable the field to measure progress.
Lastly, we need controlled studies eval- uating the development, continued use, and clinical impact of the skills and approaches taught in these workshops. Researchers may also wish to focus on the comparative effec- tiveness of workshops for different kinds of clinicians. For example, some workshops may be more useful for outpatient versus inpatient or early-career versus experienced profes- sionals. Ideally such studies would be con- ducted using observational data of real-world application of skills and patient response.
CONCLUSION
There are several theoretically valid workshops available for mental health pro- fessionals in the assessment and management of suicide risk. The large number of clini- cians who participate in workshop education each year underscores the importance of training as a suicide prevention strategy (Mann et al., 2005) and highlights the urgency of determining the effectiveness of workshops and taking steps to maximize their impact on patient outcomes.
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Manuscript Received: June 29, 2010 Revision Accepted: November 20, 2010
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